Disentangling the reasons why older adults do not readily participate in cancer trials: a socio-epidemiological mixed methods approach.

BACKGROUND: Few studies of the under-representation of older adults in cancer clinical trials (CTs) have encompassed the entire pathway from a trial being available in a cancer centre to the patient's invitation to participate and then agreement or refusal to participate. OBJECTIVES: The study's primary objective was to evaluate CT non-invitation and refusal rates. The secondary objectives were to identify factors associated with non-invitation and refusal and to assess experiences of CT participation from the patients' and professionals' perspectives. METHODS: Here, we used mixed methods and a socio-epidemiological approach to analyse reasons for the non-participation of eligible older patients with a solid cancer in cancer CTs in France. RESULTS: We found that non-invitation and low CT participation are mainly related to the patients' sociodemographic characteristics and living conditions (such as social isolation, being single, divorced or widowed, not having children and the absence of close family members) and the healthcare professionals' perceptions of insufficient informal support or a high homecare requirement. CONCLUSION: Our results suggest that efforts to increase fair inclusion and the participation of older adults in CTs should target the physician-patient relationship, the medical profession and hospital funding, rather than the patient alone.

Health, illness and cancer in Mayotte: Multicultural experiences in a medically underserved French Territory.

The island of Mayotte is part of the French territory and one of the European Union's Outermost Regions but there is a significant lack of data and research on health and cancers in Mayotte. This article reviews the literature on health, disease and cancer in Mayotte, from the perspectives of social science and epidemiology. It starts by shedding light on the specificities of Mahoran demography and society, and shows the healthcare infrastructure is insufficient to meet the population's needs. It then reviews social science studies on health and illness in Mayotte and shows that the political issue of migration permeates the management and the experiences of health on the island. It ends with a focus on the epidemiology of cervical cancer and a review of the available data on screening, treatment and prevention. The article concludes with a quick review of ongoing research and urgently calls for more data and research on this critical public health issue.

Health, illness and cancer in Reunion Island: Health services in a diverse but aging French territory.

The major social, cultural, economic and demographic changes in Reunion Island in the last 70 years have had effects on its population and the evolution of its public health issues. The demographic transition and changes in lifestyle have led to a rapidly aging population with increased needs for care for dependency and chronic illness such as cancers. The aim of this paper is to offer a review of the literature and ongoing research on health and cancer in Reunion Island. It reviews the recent literature on these changes, including the socio-demography of the population, the medical demography and cancer care infrastructure. It highlights the significant social inequalities of the island, and shows its medical demography and healthcare services are close to national averages. It then offers a review of publications on the experiences of health and illness in Reunion Island in a multicultural and postcolonial context, between medical pluralism and biomedicine. It then offers a focus on the epidemiology of three cancers, namely breast, cervical and prostate cancers. It concludes with a review of known ongoing research, and calls for a rapid adaptation of the organization of the medico-social system, in order to face Reunion Island's most pressing healthcare issues: chronic illnesses such as cancers, and dependency.

Including older patients in cancer trials: A qualitative study of collaboration between geriatricians and oncologists.

BACKGROUND: The under-representation of older patients in cancer trials remains an important obstacle to the generation of data on efficacy and safety in this growing patient population. In France, geriatric oncology coordination units (UCOGs) have been created to help oncologists and geriatricians work together on research, best practice, and continuing medical education. Taking these units as a case study, this paper sheds light on the collaboration between geriatricians and oncologists in the inclusion process of older patients in cancer trials. MATERIALS AND METHODS: Empirical data were gathered in a series of sociological interviews with all 16 oncologists, geriatricians and unit coordinators in the five UCOGs in the greater Paris region of France. RESULTS: The case of French geriatric oncology coordination units shows the gap between professional research cultures in oncology and geriatrics that may account for the low observed inclusion rates. It is easier to include patients in randomized clinical trials than in observational studies. UCOGs have the potential to improve research in geriatric oncology by catalyzing the development and implementation of effective collaboration tools (such as frailty assessments). The units also have the potential to promote Phase IV trials and observational research that are suitable for older patients with cancer. DISCUSSION: Bridging the cultural gap between oncologists (the dominant force in setting the cancer research agenda) and geriatricians (a source of specific knowledge and know-how) is essential for producing relevant trial protocols that match the specific yet diverse features of older patient populations.

Promoting patients' rights at the end of life in a geriatric setting in France: The healthcare professionals' level of knowledge about surrogate decision-makers and advance directives.

OBJECTIVE: To assess levels of knowledge about patients' rights, surrogate decision-makers, and advance directives among healthcare professionals at three hospitals in France. METHODS: A multicenter, cross-sectional study in three geriatric hospitals in the Paris area (France) in 2015. The participants' level of knowledge was assessed via an 18-item self-questionnaire on surrogate decision-makers, advance directives, and end-of-life decision-making. The characteristics associated with a good level of knowledge were assessed using logistic regression. RESULTS: Among the 301 healthcare professionals (median ± standard deviation age: 40.4 ± 10.2 years; women: 73.4 %), only 15.0 % (95 % confidence interval (CI): [19.7-29.5]) correctly answered at least 75 % of the questions on patients' rights. Respectively 24.6 % [19.7-29.5], 36.5 % [31.1-42.0] and 37.5 % [32.0-43.0] had sufficient knowledge regarding "surrogate decision-maker", "advance directives", and "decision-making at the end of life". In a multivariable analysis, the only factor significantly associated with a good level of knowledge about end-of-life policy was employment in a university hospital, with a non-significant trend for status as a physician. CONCLUSIONS: Our survey of staff working in geriatric care units highlighted the poor overall level of knowledge about healthcare surrogates and advance directives; the results suggest that additional training in these concepts is required. PRACTICE IMPLICATIONS: Continuing education of healthcare professionals on advance directives and surrogate decision-maker should be promoted to ensure rights of elderly patients at the end of life.

Inclusion of Older Patients with Cancer in Clinical Trials: The SAGE Prospective Multicenter Cohort Survey.

BACKGROUND: The primary objective was to evaluate the rates of older patients with colorectal cancer (CRC) who were eligible for a clinical trial, invited to participate, and, ultimately, included. The secondary objective was to assess the reasons for ineligibility, noninvitation, and noninclusion and factors associated. MATERIALS AND METHODS: The Sujets AGés dans les Essais Cliniques (SAGE; Older Subjects in Clinical Trials) multicenter prospective cohort was established in seven centers (10 departments of medical oncology, digestive oncology, and digestive surgery) between 2012 and 2016. All patients with CRC aged 65 or older were studied. The endpoints were clinical trial availability, patient's eligibility, invitation, and enrollment in a trial. RESULTS: We included 577 older patients (mean age ± SD: 75.6 ± 7 years; males: 56%; metastasis: 41%). Thirty-seven trials were ongoing (one trial for older patients). Of the 474 patients with at least one available trial for their cancer stage and site, 127 (27%) were eligible; 84 of these 127 (66%) were invited to participate, and 70 of these 84 (83%) were included. In a multivariate analysis, noninvitation was found to be associated with older age (p = .016): adjusted relative risk (95% confidence interval), 0.14 (0.02-0.60) for ≥80 vs. 65-69; 0.54 (0.18-1.04) for 75-79 vs. 65-69; 0.47 (0.17-0.93) for 70-74 vs. 65-69. CONCLUSION: Three-quarters of older patients with CRC were ineligible for a clinical trial. One-third of the eligible patients were not invited to participate in a trial, and 17% of invited patients were not included. Few trials are reserved for older patients. Patients aged 80 or older were significantly less likely to be eligible for a trial and invited to participate. Clinical trial identification number: NCT01754636. IMPLICATIONS FOR PRACTICE: The results of this study suggest that barriers to participation of older patients in clinical trials are particularly marked at age 80 years or older. Secondly, the results emphasize the need for trials for older patients. Thirdly, there is also a need for more pragmatic "real-world" trials, rather than solely randomized trials performed in idealized settings with strictly selected patients. Large prospective observational cohorts with a precise follow-up of toxicity, functional decline, and quality of life may constitute one way of generating more data on the risk-benefit ratio for cancer treatments in older patients.

[Hepatitis C in prison: an opportunity for healthcare]. / L'hépatite C et la prison : une opportunité de soins.

Prison inmates constitute a vulnerable population, in which socially excluded, poor and marginalized individuals are overrepresented and infectious diseases are more prevalent than in the general population. The poor health of inmates and recently released inmates is a rarely studied public health problem. The health trajectories of inmates living with the hepatitis C virus is an interesting case study to discuss public health interventions in prison. It is presented here as part of a socio-anthropological study of inmates and healthcare professionals in France. These trajectories shed light on treatment and healthcare experiences, within their economic, social, material and institutional constraints. They are an integral part of the public debate on prison health in France, comprising two prominent positions : the "pathogenic prison" and the "healing prison". These extreme positions in the broader context of this debate provide a better understanding of the context and obstacles to public health initiatives in prison and suggest ways to make them more effective.

[Hepatitis C in French prisons]. / L'hépatite C dans les établissements pénitentiaires français.

Access to screening for and treatment of hepatitis C is still insufficient in prisons.The health care of prisoners is nowthe responsibility of the ministry of health with the setting up of consultation and outpatient care units, or healthcare units, attached to a specialist hospital.